The History of the Mental Health Movement
This summary is based on the book Mental Health in the United States, a fifty-year history (1961) by Nina Ridenour. Throughout the book there is an element of propaganda. In addition, throughout the entire described period there is a preoccupation with how to mobilize public opinion and how funds can be acquired to meet the stated goals. These interrelated elements are no doubt explainable by the fact that, particularly in the early years, the movement was largely dependent on private donations. Later funds were provided by the federal government. Such funding is determined by law, and is thus more a political matter than until recently in the Netherlands, where more cooperation between civil service and private organizations exists. This means that it was and is essential for such a movement to mobilize public and political opinion. This is also why plans that are clear, demonstrably necessary, regulatable, and in particular, politically attractive, are preferred. Obviously, in such a system, there will be a temptation to “oversell.”
The history of the Mental Health movement begins in 1909 when the National Committee for Mental Hygiene was erected. The committee’s goals were the preservation of mental health, prevention of psychiatric disorders, and improvement of care, among others. The initiative came from Clifford W. Beers, himself an ex-psychiatric patient who, after his release, crusaded to bring mental health and mental illness to the attention of his fellow citizens. The committee was, and later remained, an organization that was primarily concerned with society, not with the mentally ill individual. The committee’s first activity was typical – a resolution to lobby congress for mandatory systematic psychiatric assessment of all immigrants, with the purpose of returning those who turned out to be psychiatric patients to their ports of departure. Ridenour defends this position by emphasizing that the fate of immigrated psychiatric patients was tragic. Not infrequently the contact between the patient and the family was lost once the patient was in an institution. I note that returning them can never have been in the best interest of the patients, as it would have unavoidably caused permanent separation from their families. Furthermore, it is not apparent how the mental health of these patients was served by refusing them entry. From a political point of view, such a measure cannot be considered anything but discrimination against psychiatric patients, as well as confirmation of the hypothesis that the Committee was not so much concerned with improving the fate of individuals, but rather primarily served the interests of society and the nation. Other activities as well were not intended, at least not primarily, to benefit individual patients, but society at large. Statistics about how many patients were in the hospitals began being compiled; summaries of existing laws were designed; the use of standard nomenclature was promoted; the public was informed; and government was mobilized. Apparently it was assumed that a psychiatric disorder is a given fact, and that someone who has one belongs in an institution to be treated.
The year 1921 marked the beginning of the “child guidance” movement. Its goal was to prevent juvenile delinquency through involvement of the Child Guidance clinics in youths’ lives. These clinics, rooted in society, cooperated with juvenile judges, schools, and the like. This can be considered a medicalization of asocial or antisocial behavior. This medicalization was further advanced when the American Orthopsychiatric Association was founded in 1924 at the initiative of Karl Menninger. Its aim was to promote the “medical view of crime,” namely that criminals should be considered psychiatric patients. This implies that they are not evil but ill and should be treated accordingly, so without punishment. The question of whether someone should be incarcerated is deemed irrelevant to the question of whether he is guilty. The important question is whether he will commit (another) crime. In his last book, The Crime of Punishment (1968), Karl Menninger claims that punishing criminals is criminal. This opens the way for Szasz to score an easy point. “We are thus asked to believe that the illegal acts of criminals are the symptoms of mental illness, and the legal acts of law enforcers are crimes. If so, the punishers are themselves criminals, and hence they too are ‘ill, not evil.’ Here we catch the ideologist of insanity at his favorite activity – the manufacture of madness.” (Ideology and Insanity, pp. 8-9). Ridenour states that the Orthopsychiatric Association was of great influence, particularly on clinical work. She does not elaborate on this.
The Mental Health movement had a significant role in the organization of mental health care provisions for the military during both World Wars. The American public was deeply impressed by the fact that during World War II 1,750,000 men were rejected for military service on psychiatric grounds, and another 750,000 were released from active duty for the same reasons. According to Ridenour this fact had an important educational impact on the nation because people began to better understand the nature and prevalence of psychiatric orders.
In 1946 William C. Menninger founded the “Group for the Advancement of Psychiatry.” This group promoted the idea that psychiatry should not be concerned only with patients and their treatment, but first and foremost with normal people and social action. Politics were at the center of their activities. Thus mental health gradually began to form a problem for the entire nation and society. In 1947 the WHO defined health as follows: “A state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity.” Ridenour praised the WHO for a “lofty definition of health.” In my opinion this description of health is not only utterly idealized, but also expands the domain of research and involvement of health professionals to an almost extreme extent: from now on all of society is included.
At the time, optimism about psychiatry was rife. Mora quotes Alan Gregg, who in 1944 expressed this optimism as follows: “Psychiatry, along with other sciences, gives us a sort of oneness-with-others, a kind of exquisite communication with all humanity, past, present, and future … Psychiatry makes possible a kind of sincere humanity and naturalness…”
The Mental Hygiene movement, which after 1947 became the Mental Health movement, has always promoted the idea that mental health is a government responsibility. It lobbied for legislation regarding involuntary commitment of the mentally ill and special trial procedures for mentally ill criminals. Ridenour labels such legislation as laws for the protection of the mentally ill without a word about the moral problems posed by such legislation, or the question of patients’ rights. Also noteworthy is her observation that psychiatrists are reluctant to testify in court, which she ascribes to their fear of the “battle of experts.” This refers to the conflicting reports sometimes submitted to courts by psychiatrists testifying for different parties. Her advice is, “No one will deny that the defendant must have the privilege of expert testimony, but psychiatrists can stay out of the trap and fulfill their moral obligations if they are wise enough to follow the principles of the Briggs law, and testify only on the request of the court, and with the court bearing costs.” This comment, too, demonstrates that preoccupation with the justice system and with psychiatric esteem was greater than with the interests of the individual. According to Ridenour’s proposal, if a defendant feels that he has been judged unfairly and wishes to present a counter-expert witness, he will be denied the opportunity.
In the forties of the twentieth century, the change of expression from “Mental Hygiene” to “Mental Health” led to a change in focus of which Ridenour did not unambiguously approve. The emphasis on health meant increasing attention to prevention while the patient was forgotten. In addition, the concept of mental health is so complicated that confusion of concepts was inevitable.
In the fifties support was gained for the idea that government was responsible not only for the care of patients in institutions, but also for patients who remain free in society. Moreover, according to Ridenour, government is responsible for the mental health of the entire nation.
Referring to the relationship between religion and psychiatry, Ridenour observes that spiritual leaders wish to learn from psychiatrists, but the possible contribution of religion to psychiatry is never discussed. Clergy take courses on emotional conflict and mental disorders. Some churches require their candidate clergy to have psychological examinations to rule out mental illness and to help candidates learn to know themselves. Apparently spiritual leaders are also expected to promote mental health.
The mentality of the Mental Health movement, as described by Ridenour, resembles that of the crusaders. There is constant preoccupation with the immensely important message, and the public that consistently refuses to listen. “Many of the professionals were messianic about their work.” Accordingly, in 1938 Kingsley Davis, a sociologist, described the “mental hygiene” movement as a social movement which is considered a panacea by its supporters. He asserted that the generally accepted ethic is implicitly (he used the word “unconscious”) present in images of mental health and illness, and determines them. This makes the Mental Health movement one that promotes the established ethic in a psychologizing way, whereby moral and political backdrops are veiled by the terminology of illness and health, and whereby social factors insofar as they contribute to the causes of mental illness, are consistently not considered.
After World War II mental health professionals increasingly learned to deal better with the press and public relations, which benefited the intensity of their propaganda. All means justified the end. Ridenour underlines the propagandist value of a photograph taken in a Mental Hospital in 1946, showing “… half a dozen naked, emaciated men huddled against the peeling plaster wall, defeat, despair, degradation crying out from every line and shadow – stark human misery at its nadir.” Was this anti-propaganda for further psychiatrization? On the contrary, it was a source for enormously much publicity and requests for more funds and facilities.
Directly out of the Mental Health movement grew community psychiatry. Funds became available for it, which led to the establishment of the National Institute for Mental Health (NIMH) in 1946. In 1955 funds were appropriated to a national study, which was finished in 1961, and titled Action for Mental Health. Mora calls this a milestone in American psychiatry. In this study the plan to shift the care for psychiatric patients form the Mental Hospitals to the community unfolded. The Community Mental Health Centers (CMHCs), intended as centers for psychiatric assistance, consultation, and prevention, were supposed to provide services to as many people as possible from all walks of life. They were not only, and as it later it turned out, not primarily, meant for treating patients. These centers were intended for changing society on the whole and solving various social problems.
Controversy developed between those who wanted the CMHCs to have a curative approach, as, for instance, existed in many out-patient clinics, and those who advocated a more behavioral-scientific and collective approach. This controversy had an ideological background. The out-patient clinics were about curing patients, whereas the CMHCs were intended for the community with a mixed program of curative, preventative, and public health service. On the side, I wish to mention that a remarkably similar controversy developed in the Netherlands in the early eighties of the twentieth century between the Regional Institutions for Mental Health (RIAGGs) that were being erected and psychiatric out-patient clinics. In the United States the out-patient clinics lost the contest in 1963 because President Kennedy chose the side of the NIMH and the CMHCs.
Szasz calls the Mental Health movement a typical social reform movement, its main thrust being disdain for the individual, in this case, the psychiatric patient. The patient must be helped, but does not have to be respected. Szasz considers this movement a scion of a larger social-intellectual movement, which Hayek named “counter-revolution of science.” The individual is turned into an object. The group is considered much more important than the individual. The purpose of the social sciences, in imitation of the physical sciences, is to predict human behavior and thus control it. Disdain for man as an autonomic individual, according to Szasz, is intrinsic to this approach. Also, this movement exposes the aspirations of the “scientific” elite to dominate the masses to whom they condescend. Beers opposed the idea that disturbed behavior could be meaningful and understandable. He preferred the view that mental illness is equally senseless as physical illness. In this respect Szasz considers psychopharmacology as another means to control human behavior. Psychiatric drugs are good for psychiatrists because they undergird their medical identity. Community psychiatry “complements and reinforces the posture of a drug-oriented, quasi-medical approach to human problems.” The goals are collectivism and social order and tranquility. The individual only has a right to exist if he is well-adjusted and useful. If he is not, he has to be “treated” until he is. Szasz approvingly quotes Kingsley Davis: What is called healthy behavior is in fact behavior that conforms to the most established ethical and behavioral rules of the moment. The goal is not to prevent illness, but to prevent deviation.
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